Health
In the second of TNM’s two-part series, we attempt to unpack the complex social structures and biases that may compel couples to opt for, and continue to try IVF.
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Sunitha* underwent her first IVF cycle five years ago. After trying and failing to conceive naturally, and under tremendous pressure from her family and her husband’s side to have children, she felt compelled to give In-Vitro Fertilisation a shot. Another source of pressure came from her mother, who kept telling her about a friend who now had a child thanks to the procedure. 

“I adhered to all the prescribed hormones and treatment and went through two IVF cycles at a private hospital in Mumbai,” the 35-year-old tells TNM. “I didn’t have much of an idea of what to expect, but they certainly pitched it as though it were guaranteed to work. But when the embryos didn’t take (to the uterine lining), I felt I had let my family down.”

In IVF, a woman’s eggs are extracted from her uterus and fertilised using the man’s sperm in a laboratory setting. The fertilised eggs - or embryos - are then implanted into her womb. She undergoes further treatment to improve the probability of at least one of the embryos attaching to her uterine lining, enabling her to get pregnant.

It is a difficult procedure to go through, even if hopeful couples may come out as happy parents at the end of it. IVF is one of the methods under Assisted Reproduction Technology (ART), which couples who have difficulty conceiving due to a host of issues can opt for. IVF is also expensive - the cost can run into lakhs of rupees - and is emotionally and physically exhausting, especially for women who are at the receiving end of the injections, hormones and other medication. 

Though medical advancements in recent years have vastly improved couple’s chances of fulfillment, the narrative surrounding IVF still largely consists of positive outcomes, which not only glosses over emotional costs but also hides the fact that the success rate for the procedure is less than 50%. Further, the lucrative industry, worth millions of dollars, is fuelled further by the social pressures that couples, especially women, face to have children once they are married. 

In part two of TNM’s two-part series, we attempt to unpack the complex social structures and biases that may compel couples to opt for and continue to try IVF. Read part one here.

Unsolicited advice and family expectations

Having a child is something very intimate to a couple. However, in our culture, families and friends often feel entitled to know about why you have or haven’t had children, and to offer suggestions and advice that range from rituals to doctors they can consult. 

After the first cycle failed, Sunitha did not want to put herself through IVF again, and her husband was supportive. However, the pressure from the families started mounting again when she was 33. The couple felt compelled to try once more. After three more unsuccessful rounds of IVF, the couple gave up - much to their relief - and is now considering adoption. 

“But the difficult part is dealing with family, especially when there are functions and gatherings. It feels like an ambush sometimes, like either everyone is taking a jab at me, or giving me suggestions of what my husband and I can try next,” Sunitha says.

Bengaluru-based Sudha* also felt this acutely. The 36-year-old went through three IVF cycles - one in Bengaluru and two in the US, before she had a baby girl. Before this, neither her nor her husband Ramesh’s* immediate family pressured them to have children. However, the invasive questions and unsolicited advice were aplenty from extended family, especially at functions. 

Sudha devised an ingenious way to deal with it. 

“I used to sit in the rooms where all the men were because they would not feel comfortable asking me about these things. I wouldn’t want to go to the kitchen and be where my female relatives are. It’s such a private thing for the couple, yet no one thinks twice before getting involved,” she shares.

When Vishakha*, a 35-year-old woman who was based in Chennai, and her husband Madhav had trouble conceiving naturally some years ago, their difficulties turned into a blame game for her in-laws. “After the initial investigations, my mother-in-law actually said, ‘thank god, the problem is with you and not my son.’ Till that time, we had thought of it as our problem. Though my husband reprimanded his mother, it’s not something that you can let go of easily,” Vishakha says.

What followed were endless suggestions about going to temples, performing holy rituals, going to various doctors, and trying alternative medicine. “I have tried everything – homeopathy, Ayurveda, performed poojas…  After a point, you just stop believing in god. I have not committed any sin, why should I have to do this? Once I just snapped at my mother - if god didn’t want us to have kids, so be it,” Vishakha recalls.

After two unsuccessful IVF cycles, Vishakha and Madhav did conceive naturally. However, her mother-in-law’s words sting to this day. “Today, even though I have two children, when I think about what she said, it hurts me,” Vishakha says.

The problem is compounded by the fact that because of societal inequalities, many women still have to choose between having a family or a career, points out Dr Sylvia Karpagam, a public health researcher. If women delay having a child to focus on their career because of this, they end up being blamed more.

Dr Sylvia has redirected several women to other gynaecologists who take a look at their tests and find nothing specific wrong. “The relief they feel when they are told they are OK, and they should just wait and try again before going through ART procedures is so palpable,” she notes.

At the same time, having a family’s support can make a world of a difference. 36-year-old Rashmi went through five IVF cycles in Bengaluru and Mumbai before she got pregnant. Her family and her husband’s were clear that they should not have children out of obligation to their parents, and it should be Rashmi and her husband’s decision alone. “Though it’s not rational, you’re already thinking if you had done something differently, it (a failed IVF cycle) might have worked. If I felt I was letting my parents down, it would have been far too much to handle at the time,” Rashmi says.

The emphasis on having a biological child

When Sudha and Ramesh found out that they could not conceive naturally, Sudha was open to the idea of adoption, unlike Ramesh. “Maybe it was because I anticipated the questions that would come from my immediate family and how others would talk behind my back. Maybe it was the acknowledgement of the fact that there was something wrong with my body,” he says.

However, he opened up to the idea after a relative welcomed a child into their family through adoption though they had two biological children. Ramesh and Sudha even started filing their papers to get on the adoption register after a failed IVF cycle in Bengaluru. However, they did not follow through with adoption because Ramesh’s company offered to cover costs for IVF in the US. 

Dr Sylvia points out there is not enough counselling done before starting IVF in this regard. “There is little effort to tell these couples that it is OK if they want to wait and then try again, it’s OK if they choose not to have children also, and that adoption is a very real option.”

However, Dr Kirthika argues that having a child is the right of any couple, and they should not be discouraged. “We only suggest adoption to couples whose prognosis is poor or if IVF is going to fail,” she maintains.

The desire to have a biological child is also partly rooted in India’s obsession with caste, colour and religion. This is something that the IVF industry – like many others – allegedly capitalises on as well. “Couples are often told that the donors are fair, will have high IQ etc. Sometimes couples also demand for these things,” Dr Sylvia says.

However, Dr Kirthika argues that, if at all, these requests come from couples themselves and are a reflection of the society. “We do not encourage this. The donors at our facility are completely anonymous and the focus is on matching the physical traits with the recipient and on ensuring that a donor does not pass any defects or hereditary diseases to the child. In my experience, the health and wellbeing of the embryo is enough to convince the couple.”

Further, the Surrogacy (Regulation) Bill passed by the Lok Sabha in December last year also creates avenues for exploitation based on eugenics. The Bill disallowed commercial surrogacy, only permitting “altruistic surrogacy”. This means that only a woman who’s a close relative of the married couple can be the surrogate, and she won’t be liable for payment for her services.

The emphasis on the surrogate being a married “close relative” plays into maintaining the “purity” of the family unit, at the centre of which of course, is the heterosexual married couple. Most people seeking services such as IVF and surrogacy in India, are also largely middle class and above, dominant castes, who want to have a biological child to maintain their caste purity and paternity, Sowjanya Tamalapakuka, an assistant professor of Gender Studies at TISS, Hyderabad wrote.

And, as feminist activist Chayanika Shah pointed out, this bill does not do away with exploitation as it claims. The surrogate still “has to go through a whole complex technological procedure of having a ‘test tube baby’ when she does not really need it (for she has her own eggs), when she can just use someone’s sperm and get pregnant. This Bill disallows that process, because the whole idea is about purity of family.”

So, in a patriarchal society, where masculinity and virility are held sacrosanct, thus stigmatising infertility, it further compels men and families to push the woman for biological offspring.

“Men’s concerns are different from women’s,” Dr Kirthika reveals.“They often assume that their gametes are going to be replaced by another man’s so the child won’t be their own. We have to explain to them that this only happens in case they require a donor due to a medical or infertility condition. They are also concerned about confidentiality.”

While all the women TNM spoke to said that their husbands had been supportive throughout, some of them mentioned that having a biological child was more important to their husbands. For instance, Vishakha wanted to adopt before trying IVF too. In fact, she had earlier undergone three unsuccessful attempts of intra-uterine insemination (IUI), another ART method, also. But she did not want to upset her husband and adopt.

However, Sathish*, whose wife Preeti* had a bad experience with IVF at a Chennai hospital, asserts that adoption should be a very real option for couples, and not the last-ditch attempt to start a family. 

After a traumatic experience due to insensitive hospital staff and alleged misinformation about IVF’s success rate, the couple got on the adoption register in 2014. In 2016, they were able to adopt their daughter, who is now four years old. “A lot of physical financial and emotional stress can be avoided if you just adopt. Once we decided to go for adoption and our parents also expressed support, we did it. Everyone else was also pleasantly open to accepting our daughter,” he says.

IVF is not a solution to intimacy issues 

Familial and social pressures to have children, as well as the disproportionate burden of IVF and pregnancy on women, can contribute to trouble between the couple as well. Many couples are taking advantage of the easily available IVF clinics to have children to please families without dealing with other issues between them, points out Dr Ashlesha Bagadia, a Bengaluru-based psychiatrist with specialisation in perinatal psychiatry and women’s mental health.

“Many of them disregard obvious marital problems or lack of sexual intimacy and seek IVF as an easy way so that they can please family members, without addressing their main problems,” she observes.

Further, a procedure like IVF can take a toll on their mental health as well, and Dr Ashlesha observes that couples are unlikely to consult a mental health practitioner. In her experience, they are more likely to come if one of them is, say, on medication for a mental illness and wants to seek advice before planning a pregnancy. “I also see quite a few couples who have marital discord or are leading otherwise stressful lives and are unable to conceive naturally,” she tells TNM.

Another time that couples, especially women, may need therapy is after multiple failed attempts at conceiving. “Women with such experiences are more prone to postnatal or antenatal depression. Families may add more pressure on the couple for a baby. Having a baby after multiple tries can make the couple anxious and overprotective, which may not be the best for the child,” Dr Ashlesha cautions.

There is no denying that the wonders of ART, including IVF, have given numerous couples the joy of having a child. However, their experiences beg for better awareness of emotional costs, sensitivity about the social context in which the industry operates, and proper psychological support to those who go through it. Sudha perhaps sums it up the best. “Giving birth to a child is special. I have my daughter now so it’s not as though IVF wasn’t worth it. I just wish it was easier to consider other options, to say we’re adopting, or to feel normal about not having a child.”

*Names changed

(Inputs from Dr Nimeshika Jayachandran)

Also read: How couples who go through IVF are left unprepared for its emotional costs